Diabetes Mellitus

Because of the extensive burden that diabetes mellitus imposes on individuals and healthcare systems, this disease state is frequently on the priority lists of managed-care organisations for improving quality of care while controlling costs. This article explains diabetes disease management concepts and interventions aimed at improving clinical outcomes illustrated with details of the Lovelace Health Systems Diabetes Episodes of Care® programme.The effectiveness of diabetes disease management programmes can best be evaluated by the clinical outcome of haemoglobin A_1c measures. Process measurements include diabetes education access, annual eye examinations and documentation of annual clinical evaluations of feet. Short term cost reductions are frequently unrealistic expectations of diabetes disease management programmes because of the complex, chronic nature of the disease. Coordination of previously fragmented services, eventual reduction of long term complications and meeting regulatory standards are potential achievements of these programmes.     

Lipid Clinics as Disease Management Programmes in the United States

Aggressive lipid disorder therapy in both primary and secondary prevention has been shown to reduce progression of coronary heart disease, reduce mortality and clinical events and ultimately reduce healthcare costs. Outpatient cardiac centres, diabetic treatment clinics, multispecialty medical groups, primary care medicine, and health management organisations currently have a unique opportunity to establish cost-effective lipid management programmes.Lipid clinics involve more than drug therapy and formulary management. Lipid clinics fit well within the genre of disease management; they target algorithmically driven therapy to high risk populations using intensive patient education, frequent follow-up and proven behaviour change strategies. Properly planned and organised, lipid clinics significantly enhance therapeutic compliance and lipid goal achievement compared with usual care. Successful lipid clinic operation also requires judicious staffing, sufficient patient volume, efficient referral mechanisms, tracking of outcomes measures, business development skills, and eventual integration with more comprehensive cardiovascular disease risk reduction services.This systematic approach to lipid management and cardiovascular disease risk reduction will afford meaningful opportunities for physician groups and integrated healthcare systems who aspire to reduce the unnecessary burden of premature cardiovascular disease.     

Disease State Management Programmes

Disease state management (DSM) is a new concept in healthcare which is rapidly growing in terms of interest and potential as an effective approach to improving patient outcomes. The term DSM refers to a ‘systematic population-based approach to identify persons at risk, intervene with specific programmes of care, and measure clinical and other outcomes.’ This alternative method for ‘managing care’ is being driven by an increased understanding of best practices coupled with new technologies for changing behaviour and measuring outcomes. The concept of health promotion coupled with a systems approach to healthcare could significantly improve clinical outcomes while reducing costs for many people with chronic diseases. This article describes the experience of one health plan with DSM. In addition, guidelines are presented to assist the reader in evaluating their own organisations’s ability and needs regarding disease management.     

Creating the future. Nurses can shape their profession by getting involved in healthcare reform

To remain relevant in a reformed healthcare system, nurses will have to redefine and remake themselves. Three aspects of the new healthcare age--megahospitals, managed care, and redefined professional roles--will have a significant impact on healthcare professions, including nursing. Across the United States hospitals are merging to form sophisticated networks that provide a continuum of care. Under this delivery model, nurses will play a variety of new roles and work collaboratively with the entire spectrum of health social service professionals. A related development--the growth of managed care--is an increasingly attractive option among large employers. It will also accelerate changes in the way healthcare professionals work. Managed care will force physicians to enter into appropriate group affiliations and hospitals to reconfigure themselves to meet the needs of a dynamic system that no longer requires yesterday's beds or management structures. The future will force healthcare professionals to go through regular, radical changes in their job requirements. But it will also allow nurses and others to emerge from their task-oriented past and take on work that requires them to think, judge, and intervene.     

Attractiveness of people‐centred and integrated Dutch Home Care: A nationwide survey among nurses

The World Health Organization is calling for a fundamental change in healthcare services delivery, towards people‐centred and integrated health services. This includes providing integrated care around people′s needs that is effectively co‐ordinated across providers and co‐produced by professionals, the patient, the family and the community. At the same time, healthcare policies aim to scale back hospital and residential care in favour of home care. This is one reason for the home‐care nursing staff shortages in Europe. Therefore, this study aimed to examine whether people‐centred, integrated home care appeals to nurses with different levels of education in home care and hospitals. A questionnaire survey was held among registered nurses in Dutch home‐care organisations and hospitals in 2015. The questionnaire addressed the perceived attractiveness of different aspects of people‐centred, integrated home care. In total 328 nurses filled in the questionnaire (54% response rate). The findings showed that most home‐care nurses (70% to 97%) and 36% to 76% of the hospital nurses regard the different aspects of people‐centred, integrated home care as attractive. Specific aspects that home‐care nurses find attractive are promoting the patient′s self‐reliance and having a network in the community. Hospital nurses are mainly attracted to health‐related prevention and taking control in complex situations. No clear differences between the educational levels were found. It is concluded that most home‐care nurses and a minority of hospital nurses feel attracted to people‐centred, integrated home care, irrespective of their educational level. The findings are relevant to policy makers and home‐care organisations who aim to expand the home‐care nursing workforce.     

Breast Cancer Epidemiology,Prevention and Costs of Care

Breast cancer is the most frequently diagnosed cancer in women and the second leading cause of cancer mortality. It is estimated to account for approximately 20% of all cancer expenditures, making the burden of disease relatively high. One of the most important risk factors for developing breast cancer is age; with demographic trends towards an increasing elderly population in the US, this burden is likely to increase. Recent trends in healthcare delivery have increased the emphasis on evaluating costs of providing care as well as the outcomes of that care.This paper reviews breast cancer epidemiology, primary and secondary prevention and costs of breast cancer care by stage of disease at diagnosis and type of service, and discusses implications for the development of disease management programmes. Implementation of disease management programmes, through the creation of a data infrastructure system, establishment of measurable breast health and cancer care outcomes, and programme evaluation may be an important mechanism for managed-care organisations to provide quality and cost-effective breast cancer management.     

Health and Disease Management Within an Academic Health System

’Health and disease management’ is a clinical improvement process aimed at ensuring that the best practices known to medical science are incorporated with minimal variation over the entire continuum of care. The University of Pennsylvania Health System (UPHS) is an academic, integrated healthcare delivery system committed to implementing this approach to care by all providers and at all sites. This report outlines our approach to design, implementation, outcomes tracking and improvement, and highlights how the educational, service and research missions of the academic health system add value to the comprehensive health and disease management approach.The involvement of clinical researchers and academic physicians in the design of programmes contributes directly to improved clinical outcomes. Faculty with specific research interests, and experience with less common conditions, frequently lead this best-practice approach with rarer conditions, so allowing the impact of these programmes on improving the quality of care to be evaluated across many disease states. On the basis of their extensive knowledge of the disease in question, academic faculty play valuable leadership roles in selecting relevant key measures.Education, a key component of health and disease management implementation, is an area of particular strength in academic systems. Provider education, in particular, can be effectively achieved by academic detailing, led by specialists and utilising the involvement of skilled educators.A key requirement for programmes such as these is the need to frequently update the best-practice clinical guidelines. The academic health system is ideally poised to rapidly incorporate clinical advance and emerging knowledge into disease management programmes that can reach a wide audience. Health and disease management offers a unique research opportunity for academic physicians who can adapt the use of process control measurement techniques, which have long been the major approach to performance measurement in industry, to the healthcare environment.Clinical evaluation and outcomes management, has the potential to become widely embraced as a legitimate and important form of research. Substantial effort and resources must be dedicated to gain provider buy-in and achieve compliance. We believe that academic health systems have many of the necessary ingredients to be successful in this initiative. Moreover, if this approach to care is to be widely adopted, and behaviour change achieved, the next generation of healthcare leaders and workers must be introduced to these concepts early in their training.     

Design,Development and Implementation of a Multidisciplinary Diabetes Disease Management Programme

Disease management initiatives are becoming increasingly popular in the US as a way for managed-care plans to care for their members with chronic conditions. Diabetes is one of the most expensive chronic conditions, both in terms of human lives and actual healthcare costs. Managed-care plans are adopting different approaches to caring for their members with diabetes. The experience of one organisation shows that a population management approach to caring for people with diabetes is the best way to improve clinical outcomes and reduce healthcare costs for managed-care organisations in the short term.     

The Role of Community Health Information Networks in Disease Management

A Community Health Information Network (CHIN) is a web-based net of computer systems which allows the electronic exchange of clinical, financial and administrative information among unaffiliated healthcare entities in order to improve the efficiency and delivery of healthcare in the community. It achieves this through a combination of services, products and technology.One field of application in which CHINs can be very effective is disease management; the aim of disease management is to align patient, provider and payer interests in order to enhance quality of care and cost savings. CHINs can be used to effectively and efficiently implement disease management programmes through linking disease management systems (i.e. computerised disease management programmes) with other information systems. The application of CHINs in the implementation of disease management programmes has many benefits including shared data, internal communication, external communication, value-added applications, bonding and marketing presence. However, there are also problems and pitfalls of an architectural and ‘emotional’ nature. Architectural problems relate to legacy system incompatibility, legacy functionality, external data representation, communications disparity, distributed governance, flexibility versus homogeneity, confidentiality, and size and scalability. Emotional problems include personal barriers, community and ethnic cultural issues, and suspicion between the various levels of care involved in an information exchange process.Many examples of operational CHINs can be found on the Internet. Although many challenges lie ahead for patients, healthcare providers and healthcare organisations in this field, these examples show that the use of CHINs will influence medical and healthcare practice in a positive way, especially in terms of disease management.     

Gaining Physician Buy-In for Disease Management Initiatives

Achieving the support of physicians is perhaps the most difficult challenge to successfully implementing a disease management programme. Most physicians are sceptical of disease management initiatives. Many perceive these programmes to be a threat to their professional autonomy or an unreasonable demand on their limited time with patients. Nonetheless, failure to achieve high levels of physician support results in suboptimal levels of patient identification, enrolment and effectiveness of interventions. Therefore, it is impossible to achieve good outcomes across a large population without achieving physician buy-in.Leaders of organisations implementing disease management programmes can use 5 core strategies to achieve physician buy-in for disease management programmes. These are: education, enlisting champions, ‘creating a box’, building on success, and sharing the gains. Providing education corrects misconceptions many physicians have about disease management. Champions are respected clinicians who are willing to share their positive views of a disease management programme. ‘Creating a box’ sets clear goals and expectations for physicians who consider building a disease management programme. Building on success involves demonstrating that a relatively easy programme works before attempting a more complex or controversial programme. Finally, sharing the gains means that physicians should be rewarded for their time and effort supporting disease management programmes.     

Interactive Voice Response in Disease Management

The effective management of chronic illness has historically been plagued by patient non-adherence to treatment regimens. While disease management initiatives have recently proliferated in an attempt to more effectively manage these chronic illnesses, many of these new programmes have lacked effective behaviour change interventions. It is expected that this void will hopefully be corrected as more sophisticated second generation disease management programmes are developed.This article explores the major issues and forces driving patient non-adherence and recommends a number of strategies to be used to enhance patient adherence and to improve patient self-management. Specifically, the authors propose 6 guiding principles for improving patient adherence and self-management. These principles include: (i) taking a comprehensive, holistic, patient-centred approach to disease management; (ii) being aware of the many different forms of nonadherence; (iii) facilitation of patient motivation and readiness to change; (iv) collaboratively supporting self-management behaviour; (v) focusing less on problems and more on solutions; and (vi) establishing and maintaining good communications with the patient.The success of disease management will require, in many cases, a major reengineering of how we deliver and coordinate healthcare. Importantly, the development of systematic behaviour change interventions and adoption of a true patient-centred approach to disease management will be essential if meaningful, long term clinical and economic outcomes are to be achieved. Case managers and specialty disease management organisations that focus on the development of new, implementable behaviour change interventions will play a major role in insuring that our second generation of disease management programmes incorporate these new patient empowerment interventions.     

“They were all together … discussing the best options for me”: Integrating specialist diabetes care with primary care in Australia

Over one-third of diabetes-related encounters with healthcare providers in Australia fail to meet clinical guidelines. Evidence is mounting that care provision within an integrated framework may facilitate greater adherence to clinical guidelines and improved outcomes for patients. The Diabetes Alliance Program was implemented across a large healthcare district to enhance diabetes care capacity at the primary care level through intensive case-conferencing involving the primary care team, patients and visiting specialist team, whole practice performance review and regular diabetes education for practitioners. Here, we provide an in-depth patient assessment of the case-conferencing process and impact on diabetes management. Two practices with high pre-intervention HbA1c monitoring and three practices with low HbA1c monitoring provided the sampling frame. Patients were selected according to their score on the Patient Activation Measure^TM to achieve maximum variation, with up to two patients with high scores and three with low scores, selected from each practice. Patients were sampled until data saturation was achieved and then subjected to thematic content analysis (n = 19). Patients mostly described the model of care as a positive experience, reporting a boost in confidence in diabetes self-management (particularly around nutrition). The program was also seen to be helpful in providing an opportunity to refocus when “life gets in the way”. Other valued aspects of the program included the holistic approach to healthcare, reduced travel time, familiarity in environment and clinical care, top-down knowledge transfer as well as mutual learning by the patient and their primary care team. Despite this, difficulties in coping with diabetes and adherence to treatment recommendations remained for a minority of patients. Integrating specialist teams within primary care has the ability to provide efficient healthcare delivery, better patient experience and health outcomes. Investment in such approaches will be critical to navigating healthcare provision in order to meet the demands of an ageing population.     

An assessment of the experiences and needs of adolescents with chronic conditions in transitional care: a qualitative study to develop a patient education programme

The transition of adolescents with chronic conditions is a challenging task. This study aimed to explore the experiences and needs of adolescents with chronic conditions in the transition period and to apply these findings to the design of a generic patient education programme. Data were collected from a sample of 29 adolescents with chronic conditions from Northern Germany and Switzerland including a broad range of views due to variation in disease management and organisation of care both in paediatric and adult populations. Participants were interviewed in group (n = 18) or individual (n = 11) interviews between September 2011 and February 2012, and the data were analysed using qualitative content analysis. The findings revealed that the interviewees expressed high levels of competency in the management of their chronic conditions but identified gaps in healthcare and unmet needs during transition. In particular, they believed that they would benefit from opportunities to exchange ideas and more specific information with peers about vocational and medical issues concerning adolescent health. Identified themes reflecting adolescent needs were used to develop the transition workshop including modules regarding the following: transfer to adult medicine, their new role as a patient, orientation within the healthcare system, vocational issues, detachment from parents, social support, contraception, substance abuse, family planning, stress‐management, activation of resources and developing personal goals. The workshop's content was largely generic and included some condition‐specific components. The workshop was designed as a compact 2‐day patient education programme in a group setting for adolescents prior to their transfer to adult care. The guiding principle was the idea of empowerment by supporting the adolescents through various interactive methods to develop adequate knowledge, skills, understanding and motivation regarding their chronic conditions. We conclude that patient education programmes promoting adolescent self‐management and empowerment increase the preparedness for transition.     

How can insulin initiation delivery in a dual-sector health system be optimised? A qualitative study on healthcare professionals' views

ABSTRACT: BACKGROUND: The prevalence of type 2 diabetes is increasing at an alarming rate in developing countries. However, glycaemia control remains suboptimal and insulin use is low. One important barrier is the lack of an efficient and effective insulin initiation delivery approach. This study aimed to document the strategies used and proposed by healthcare professionals to improve insulin initiation in the Malaysian dual-sector (public-private) health system. METHODS: In depth interviews and focus group discussions were conducted in Klang Valley and Seremban, Malaysia in 2010-11. Healthcare professionals consisting of general practitioners (n=13), medical officers (n=8), diabetes educators (n=3), government policy makers (n=4), family medicine specialists (n=8) and endocrinologists (n=2) were interviewed. We used a topic guide to facilitate the interviews, which were audio recorded, transcribed verbatim and analysed using a thematic approach. RESULTS: Three main themes emerged from the interviews. Firstly, there was a lack of collaboration between the private and public sectors in diabetes care. The general practitioners in the private sector proposed an integrated system for them to refer patients to the public health services for insulin initiation programmes. There could be shared care between the two sectors and this would reduce the disproportionately heavy workload at the public sector. Secondly, besides the support from the government health authority, the healthcare professionals wanted greater involvement of non-government organisations, media and pharmaceutical industry in facilitating insulin initiation in both the public and private sectors. The support included: training of healthcare professionals; developing and disseminating patient education materials; service provision by diabetes education teams; organising programmes for patients' peer group sessions; increasing awareness and demystifying insulin via public campaigns; and subsidising glucose monitoring equipment. Finally, the healthcare professionals proposed the establishment of multidisciplinary teams as a strategy to increase the rate of insulin initiation. Having team members from different ethnic backgrounds would help to overcome language and cultural differences when communicating with patients. CONCLUSION: The challenges faced by a dual-sector health system in delivering insulin initiation may be addressed by greater collaborations between the private and public sectors and governmental and non-government organisations, and among different healthcare professionals.     

Improving cardiovascular outcomes in Nova Scotia (ICONS): a successful public-private partnership in primary healthcare

Broadly defined, disease, or health management, is a focused application of resources to improve patient outcomes; its premise: things can be better. In particular, the gap between what best care could be, and what usual care is, can be reduced and, consequently, care and outcomes can be improved. This paper reviews the evolution of the partnership/measurement paradigm of disease management and considers its value in sustaining Canadian healthcare. Lessons from ICONS (Improving Cardiovascular Outcomes in Nova Scotia), a major public-private health partnership of physicians, nurses, pharmacists, patients and their advocacy groups, government and industry, are highlighted. Launched in 1997, ICONS' proof-of-concept phase ended in 2002. Due to its positive impact on the cardiovascular health of the population and its integrated and accountable administrative processes, ICONS became an operational program of the Nova Scotia Department of Health. This successful community-based partnership represents a major achievement in organizational behaviour in the arena of primary healthcare. It supports optimal care as evidence-based and seamless, recognizing the patient as the nucleus. It should be considered for other disease states and constituencies where the goals are closing care gaps and delivering the best health to the most people at the best cost.     

Carve-Outs

Disease management is a strategy for patient care across the entire healthcare delivery system and throughout the life-cycle of a disease. Disease management is a new paradigm for managed care. It focuses on an alignment of interests between patient, payor and provider.But what is a carve-out, and what is its role in disease management? Is it an interim step to a disease management programme? Is it a subset of a disease management programme? Does a carve-out have benefits as a stand alone programme? This article addresses these questions by looking at both heart and cancer carve-outs versus disease management. Through these 2 examples, the parameters for disease management and carve-outs are compared.Carve-outs treat the episodic events of a disease and are effective when the disease is independent of other patient conditions, when the disease has a defined beginning and end, and when treatment for the disease is predictable and definable. When a disease has many interdependencies or cause-effect relationships with other conditions, disease management offers the best method of providing treatment for the complete life-cycle of the disease.‘Managed care’ began by managing access to goods and services, has matured to managing episodes of acute/costly care needs and is gradually migrating to managing the continuum of care needs for optimised outcomes.By implementing disease management programmes for serious and catastrophic diseases, managed care will be evolving to the next step in the process of providing quality healthcare while holding costs to acceptable levels.     

Barriers to Providing Health Education During Primary Care Visits at Community Health Centers: Clinical Staff Insights

The rapid increase of diverse patients living in the US has created a different set of needs in healthcare, with the persistence of health disparities continuing to challenge the current system. Chronic disease management has been discussed as a way to improve health outcomes, with quality patient education being a key component. Using a community based participatory research framework, this study utilized a web-based survey and explored clinical staff perceptions of barriers to providing patient education during primary care visits. With a response rate of nearly 42 %, appointment time allotment seemed to be one of the most critical factors related to the delivery of health education and should be considered key. The importance of team-based care and staff training were also significant. Various suggestions were made in order to improve the delivery of quality patient education at community health centers located in underserved areas.     

Integrated care programmes for chronically ill patients: a review of systematic reviews.

OBJECTIVE: To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. DESIGN: Literature review from January 1996 to May 2004. MAIN MEASURES: Definitions and components of integrated care programmes and all effects reported on the quality of care. RESULTS: Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. CONCLUSION: Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.     

Data Warehousing Solutions and Internet Initiatives in the Disease Management Era

Clinical knowledge and information technology play a major role in the success of disease management programs in achieving improvements in financial and clinical outcomes. The multi-dimensionality and complexity of data needed to run these programs efficiently make information management an important aspect to consider.Disease management clinicians, case managers, nurses, other providers, analysts, managers, and medical directors are constantly using financial, clinical, operational and other data, increasing significantly the demand for information in organizations. Also, with the Internet disseminating critical information among healthcare providers and patients in a more efficient way, careful adoption of new technologies and ideas is required.Consequently, disease management programs are constantly presenting new technical challenges for healthcare companies. Lacking the proper information systems structure to meet these demands can result in business productivity losses reflected in disease management programs not achieving their goals of cost savings and patient health quality improvements. An efficient disease management data warehouse is an important tools to organising and distributing information.